DPS Computerized Criminal History (CCH) Verification

Please Enter Full Name

I, (name entered above), acknowledge that a Computerized Criminal History (CCH) check may be performed by accessing the Texas Department of Public Safety Secure Website and may be based on name and DOB identifiers. (This is not a consent form, but serves as information for the applicant.) Authority for this agency to access an individual’s criminal history data may be found in Texas Government Code 411; Subchapter F. Name-based information is not an exact search and only fingerprint record searches represent true identification to criminal history record information (CHRI), therefore the organization conducting the criminal history check is not allowed to discuss with me any CHRI obtained using the name and DOB method. The agency may request that I also have a fingerprint search performed to clear any misidentification based on the result of the name and DOB search. In order to complete the fingerprint process I must make an appointment with the Fingerprint Applicant Services of Texas (FAST) as instructed online at www.txdps.state.tx.us /Crime Records/Review of Personal Criminal History or by calling the DPS Program Vendor at 1-888-467-2080, submit a full and complete set of fingerprints, request a copy be sent to the agency listed below, and pay a fee of $25.00 to the fingerprinting services company. Once this process is completed the information on my fingerprint criminal history record may be discussed with me.

Signature

Date

Internal use:

AGENCY NAME: ABUNDANT LIFE HCS COMPANY

AGENCY REPRESENATIVE (PLEASE PRINT): _____________________

AGENCY REPRESENATIVE SIGNATURE: ____________________

DATE: _________________________